School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
Does exercise increase appropriate play behavior in children with autism (ASD)?

Prepared By:
Shantel Bishoff, OTS & Jaclyn Jerse, OTS
Touro University Nevada
School of Occupational Therapy
874 American Pacific Dr.
Henderson, NV 89014

Date Review Completed:

October 13, 2014

Clinical Scenario:
Autism spectrum disorders (ASD) are a group of developmental disabilities that can cause
significant social, communication, and behavioral challenges (CDC, 2013). The Centers for
Disease Control and Prevention (CDC) estimates that about 1 in 88 children have been identified
with an ASD (CDC, 2013). More people are being diagnosed than before but the reasons remain
unknown, but are in part likely due to increased awareness. The CDC revised the ASD prevalence
estimates from 1 in 150 children to 1 in 110 children (CDC, 2013). ASD is characterized, in
varying degrees, by problems in social interaction, verbal and nonverbal communication, and
repetitive behaviors (Autism Speaks, 2013). Children with ASD present unique challenges to the
classroom teacher and the childs inability to regulate his or her own behavior can often be the
biggest struggle (Koenig, Buckley-Reen, & Garg, 2012). To date, several organizations promote
and fund autism research however few have isolated specific intervention strategies to enhance
engagement in occupation. Additionally, because ASDs presentation in each child is so varied
with symptoms ranging from mild to severe, understanding the condition and finding the best
therapies [can be] difficult (U.S. Department of Health and Human Services, 2011, p. 1).
It is important then that OT practitioners work collaboratively with individuals on the autism
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

spectrum, their families, their teachers and other health professionals to, provide a range of
needed resources and services that support the individuals ability to participate fully in life,
(AOTA, 2010, p. 1). Exercise as an intervention has become increasingly popular in the United
States. The latest "Yoga in America" study released by Yoga Journal shows that 20.4 million
Americans currently practice yoga (Yoga Journal, 2012). Exercise based activity has many
benefits including stress reduction, increased flexibility and muscle tone, improved athletic
performance, increased respiration and energy, and maintenance of a balanced metabolism
(AOTA, 2013). Yoga is classified as a mindbody intervention by the National Center for
Complementary and Alternative Medicine and can be used as a complementary approach in
occupational therapy to enhance engagement in occupation (Koenig et al., 2012). Exercise based
strategies are used as an intervention strategy in the classroom in order to increase attention,
increase social skills, decrease maladaptive behavior, and increase functioning in children
diagnosed with ASD. This review looks at the evidence behind children with ASD participating in
exercise-based interventions to make positive behavioral changes.

Summary of Key Findings:

Summary of Levels I, II and III:
Level I:
Research indicated that Kata techniques training is effective for consistently reducing
social dysfunction in children with ASD. The results of the present investigation may
help officials of autism institutions decide to establish strategic plans under which
martial arts techniques will best be instructed to children with ASD. It also offers parents
of children with ASD to encourage their autistic children to participate in Kata
techniques training programs
(Movahedi, Bahrami, Marandi & Abedi, 2013, Level I).
Level II:
Research concluded that an individualized, high-intensity exercise program is an
effective method for improving health and fitness, reducing negative behaviors, and in
improving positive behaviors of children and adolescents with ASD. Results of pre- and
post-intervention ratings by parents and guardians indicated that the frequency of
problematic behaviors and how the behaviors interfere with daily life were significantly
reduced following participation in an exercise program. The benefits of using exercise as
an intervention include its cost-effectiveness and potentially preventative nature
compared to other behavioral interventions (Magnusson, Cobham & McLeod, 2012,
Level II).
The studys findings are similar to the clinical scenario. The author of this study
concluded that a school-based yoga program used with children with ASD decreases
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

maladaptive behaviors such as non-compliance, hyperactivity, social withdrawal,

lethargy, and irritability. Significant changes were found in maladaptive behavior in the
experimental group compared to the control group. The outcome results are favorable to
the use of the GRTL yoga program as an intervention with children with ASD (Koenig,
Buckley-Reen & Garg, 2012, Level II).
Positive effects of physical activity were found to increase the duration attention spans
and quality of life of children with ASD. These results extend the findings that physical
activity enhances cognition of ASD children and support its consideration into early
intervention programs (Tan, 2011, Level II).
Research concluded that the participants that received the integrated approach to yoga
therapy (IAYT) had improved imitation skills, language skills, communication, joint
attention, play, and increased alertness. The outcome results were favourable to the use
of a IAYT program when used with children with ASD (Radhakrishna, Nagarathna &
Nagendra, 2010, Level II).
Findings support the notion that an appropriate regular physical activity program will
improve health behaviors for children with and without disabilities. It is concluded that
an aquatic program is an effective intervention option for children with ASD and their
siblings with a disability, and may be a fun alternative to land-based low-impact
physical activity program for children with disabilities and their families. By providing a
physical activity program that meets regularly, it is possible to positively impact the
lifestyle and independence of individuals, especially for those with disabilities (Pan,
2010, Level II).
Level III:
The study showed that implementation of structured play and facilitated play models
increased appropriate play and communication. The study found preliminary evidence
that respondent and spontaneous play and communication interacts with the play format
as well as the functioning level of the participants
(Kok, Kong & Bernard-Opitz, 2002, Level III).
The studys findings are related to the clinical scenario. The author of this study
concluded that the participants that received the IAYT had improved imitation skills,
language skills, communication, joint attention, play, and increased alertness. The
outcome results are favourable to the use of IAYT program when used with children
with ASD. Since the specific data of the control group was not given, it is hard to know
whether IAYT had a much greater effect than the ABA training (Rosenblatt, Gorantla,
Torres, Yarmush, Rao, Park...Levine, 2011, Level III).

Summary of Level IV and V:

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Findings from the study revealed increased percentages of observed academic

engagement for students participating in the physical activity intervention. Increases in
academic engagement correlated with the level of participation in the physical activity
such that the students who were more consistently running or walking subsequently
displayed greater involvement in the classroom (Nicholson, Kehle, Bray & Heest, 2011,
Level IV).

Contributions of Qualitative Studies:

None included in review

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT: As the health risks of a sedentary lifestyle
are more common among individuals with intellectual and developmental disabilities such as
ASD compared to those without the developmental disabilities, finding ways to increase activity
levels in this population is necessary to reduce the likelihood of negative health consequences
(Magnusson, Cobham & McLeod, 2012, Level II). Evidence suggests that occupational therapists
can bring evidence-based yoga programs to public school classrooms as a successful way to
improve maladaptive behavior (Koenig, Buckley-Reen & Garg, 2012, Level II). It is also
important to note social dysfunction as a main diagnostic feature of autism spectrum disorders.
Deficits in socialization have been found to be a major source of impairment in social interaction
for individuals with ASD; the results of a Kata technique intervention have proved to increase the
social behaviors necessary to live a meaningful and productive life, (Movahedi, Bahrami,
Marandi & Abedi, 2013, Level I). Specific physical activity interventions may increase academic
engagement in high-functioning children diagnosed with an ASD (Nicholson et al., 2011, Level
IV), as well as appropriate regular physical activity programs, such as an aquatics (Pan, 2010,
Level II). Participants who received exercise-based interventions, specifically yoga-based
represented with improved imitation skills, language skills, communication, joint attention, play,
and increased alertness. It also proved to further calm the physical body, which in-turn helped the
child become more focused and organized (Radhakrishna, Nagarathna & Nagendra, 2010, Level
II). Results prove there is a positive impact utilizing multimodal relaxation programs on the
behavioral and cognitive symptoms of children with ASD. Favorable results allow OTs to use
yoga programs in practice with children with ASD (Rosenblatt et al., 2011, Level III). Physical
activity prior to any form of learning may be an effective stimulus in early intervention services to
enhance learning; utilizing any form of physical activity proves to be suitable to childrens needs,
attention span and social functioning when diagnosed with ASD (Tan, 2011, Level II). More
concrete, specific, and replicable research is needed evaluating similar interventions that use like
outcome measures in order to make a more solidified recommendation to practitioners about
exercise-based interventions used in the clinic to benefit children with autism.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Program development: An exercise-based program promotes reduction in maladaptive

behaviors, but also suggests that occupational therapists can bring evidence-based exercise
programs to public school classrooms as a successful way to improve behavior (Koenig, BuckleyReen & Garg, 2012, Level II). When looking at facilitated and structured play, treatment
comparison studies could shed some light on optimizing play interventions. It is likely that
clinical gains can be enhanced when treatment programs can strike a delicate balance between the
motivation and ability of the child and the task structure (Kok, Kong & Bernard-Opitz, 2002,
Level III). An individualized, high-intensity exercise program is an effective method for
improving health and fitness, reducing negative behaviors, and in improving positive behaviors of
children and adolescents with ASD (Magnusson, Cobham & McLeod, 2012, Level II).

All studies reported beneficial and temporary effects of exercise in decreasing

maladaptive behaviors. Effects were greater with more intensive aerobic activity.
However, the heterogeneity of the research designs and interventions makes it difficult to
determine appropriate prescription of exercise for children with ASD. Different forms of
exercise (e.g., jogging, yoga, kata techniques, structured play) and varying measures of
exertion and intensity (e.g., flushed face, heart rate, appearance, no monitoring) further
complicate the process of making precise recommendations regarding exercise
prescription to reduce stereotypical, inappropriate behaviours in children with ASD.
Although the evidence is weak to moderately strong, the literature does suggest that
exercise produces short-term decreases in maladaptive behaviours in this population.
There is also supporting evidence that higher-intensity exercise is more effective than
lower-intensity activity in decreasing self-stimulation. Clinicians working in pediatric
practice should consider the above points when working with children with autism
displaying non-compliance, social dysfunction and maladaptive behaviours. Although the
heterogeneity of the research designs and interventions makes it difficult to determine
specific prescription of exercise for children with ASD, the studies reviewed included
various types and intensities of exercise that are clinically relevant for clinicians working
with children with ASD who have different capabilities and tolerance levels for certain
activities. Furthermore, benefits were not limited to these behaviours; several studies in
this review found improvements in other areas (e.g., academic responses, on-task
behaviours). In depth research utilizing more rigorous methods with greater numbers of
participants is needed to determine specific exercise prescriptions within OT treatment for
children with ASD. Despite these limitations, the literature does suggest that exercise has
a beneficial, albeit short-term, impact in reducing maladaptive behaviours in children
with ASD.
Societal Needs: As the number of children diagnosed with autism continues to grow, so too will
the prevalence of children with autism seeking OT services. As such, there is a professional and
societal need to identify and practice effective intervention techniques to meet said demands. As
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

mentioned previously, many children with ASD experience deficits within social and
communication skill realms that can interfere with engagement in daily life occupations and
interactions with family members, friends, and peers in a purposeful manner. Provided their
prevalent use already to aide in these areas, it is important to determine the effectiveness of
exercise-based interventions that will increase appropriate social behaviors which in turn will help
ensure that the profession is in compliance with evidence based practice by providing the most
effective treatments available.
If it is found that exercise based therapy can effectively improve social skills and communication,
children with autism who have been placed alternatively in school, may find themselves eligible
for increased inclusion in least restrictive environments. Furthermore, it is possible that improved
communication and social skills could help children be more self-sufficient and thus depend on
others and community programs less.
Studies suggest that physical activity in the form of something as simple to implement as jogging
may be efficacious in promoting academic achievement for students diagnosed with ASD
(Nicholson, Kehle, Bray & Heest, 2011, Level IV). Study results showed changes in
communication, language, play and joint attention when utilizing exercise-based interventions
(Radhakrishna, Nagarathna & Nagendra, 2010, Level II). Evidence suggests that specific yoga
programs help decrease maladaptive behaviors when used with children with ASD no matter how
severe the diagnosis (Rosenblatt, Gorantla, Torres, Yarmush, Rao, Park...Levine, 2011, Level III).
Several finding throughout this exhaustive literature review showed improvement of social
functioning in the physical activity participants, further presenting with higher results in the
PedsQL, reflecting exercise interventions to be effective (Tan, 2011, Level II).
Healthcare delivery and policy: Findings revealed increased percentages of observed academic
engagement for students participating in the physical activity interventions. It also appeared that
the increases in academic engagement correlated with the level of participation in the physical
activity such that the students who were more consistently running or walking subsequently
displayed greater involvement in the classroom. By providing a physical activity program that
meets regularly, it is possible to positively impact the lifestyle and independence of individuals,
especially for those with disabilities. Parents of each reviewed study all reported dramatic positive
impacts on their childrens lives as a result of the specific exercise-based interventions. An
increased sense of accomplishment and self-worth was also reported by the parent or guardian of
each individual child. Results suggested that a yog-based program may help to increase behavior
skills such as imitation, language, joint attention, communication, play, and alertness when used
with children with ASD (Radhakrishna, Nagarathna & Nagendra, 2010, Level II). Evidence
suggests that physical activity is capable of triggering the brains ability to change (Tan, 2011,
Level II) The evaluation of exercise-based interventions especially given its increased integration
into practice both clinically and within the health profession to treat a myriad of diagnoses and
symptoms is critical within evidence-based practice. As the need for scientifically based
educational interventions is outlined in the Individuals With Disabilities Education Improvement
Act of 2004, research addressing the effectiveness of intervention to guide evidence-based
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

practice is pivotal.
Education and training of OT students: Although many of the interventions within the relevant
studies implemented assessments and outcome measures in which the individual effectuated the
measure, had to be certified or trained within the realm of the assessment pertinent to the study,
this was not the case for all reviewed literature. The clinical reasoning and creativity that is
already part of entry-level education would allow for an introduction of the concept of each
individual measure for a number of pertinent cases. Introduction to the concepts involved in many
of the interventions however would enhance entry-level education and add to the skill set of
entry-level practitioners. However, although many of the studies present as not needing further
certification to conduct and implement, distinct training to perform specific yoga interventions
would be useful to incorporate further knowledge and credibility while implementing yoga-based
interventions (Radhakrishna, Nagarathna & Nagendra, 2010, Level II).
Refinement, revision, and advancement of factual knowledge or theory: Additional research is
needed to better understand which specific physical activity interventions are most appropriate for
specific children in various settings. Randomized control trials should be conducted in order to
provide a higher level of evidence supporting the exercise-based interventions in order to further
solidify structured, beneficial interventions. Future research should examine the effectiveness of
the many programs already within research as well as new programs in relation to academic
outcomes, performance-based executive function tasks that assess attention and focus among
students with ASD as well as behavioral outcomes to see whether improved behavior affects
educational and occupational performance.
Overall, the evidence suggests mixed results and thus an inconclusive review. Despite effective
and partial effectiveness across several studies, the limitations found within the research
aggregate require the results be evaluated and applied on a preliminary, experimental basis.
Additional research is justified if not solely to either validate and close or refute and expand the
findings of this exhaustive review. Homogenous groups, increased sample sizes, and valid and
like outcome measures should be utilized in future studies to allow for the strongest and highest
level of evidence when complete. It should also be noted that the focused question utilized in the
making of this CAT encapsulated the spectrum of available exercise-based therapies. It would be
beneficial in future reviews to complete separate reviews regarding modified and non-modified
interventions. Once a techniques effectiveness has been determined, then and only then can it be
compared to and analyzed against another. While these studies provide a jumping off point,
further research is required to determine exercise-based interventions position as a therapeutic
intervention in the advancement of factual knowledge and theory of OT practice.

Review Process:
The following process was undertaken to thoroughly and effectively evaluate the literature:
-In consultation with the course instructor, the focused question was developed and chosen out of
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

personal interest regarding the practice as well as specific interventions implemented in an effort
to target the ASD population.
-Search terms for applicable population, intervention, and outcome terms were developed and
later verified by course instructor.
-Search terms were used to exhaust databases in search of abstracts and full text articles that
contained each component.
-Abstracts that did not thoroughly identify inclusion of all components were further evaluated by
reading the article in full text to determine presence or absence of necessary components.
-Twenty articles were submitted as a result of comprehensive literature search. As per the
requirements of an Evidence-Based Literature Review, included articles had to be of evidence
level IV and above. Course instructor along with students confirmed determined level of evidence
when necessary.
-With assistance of course instructor, full-text articles of those identified in literature search were
obtained. The articles were read and reviewed in reference to focused question. Full-text articles
that did not meet identified population, intervention, and outcome were eliminated from further
analysis.
-From the twenty, five free standing articles were analyzed within a systematic review and were
thus, eliminated. High priority articles were then selected and reviewed based on level of evidence
and publication date in a peer reviewed journal for the years 1992 through 2014 in an effort to
provide a comprehensive review of the strongest and most recent evidence on the topic.
-Ten articles meeting population, intervention, and outcome standards as well as exclusionary
criteria were selected for Evidence Table and appraised for significance.
-Course instructor reviewed appraisal of articles and provided feedback regarding revisions and
article use approval for Critically Appraised Topic.
-Ten articles evaluated and approved were used to summarize key findings and clinical
significance in this Critically Appraised Topic.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:
Participants were children and adolescents with ASD under the age of 18; outcome measures were
focused on behavior change; studies looked at the effects of exercise interventions; evidence
2002-present; quantitative studies

Exclusion Criteria:
Studies that had outcome measures focused on something other than behavior; sample had
children not diagnosed with ASD; evidence prior to 2002; qualitative studies; adult and geriatric
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

population

Search Strategies:
Categories

Key Search Terms

Patient/Client Population

Autism Spectrum Disorder, Adolescence, Pediatrics,

Children, Asperger, Child Development Disorder, Pervasive
Developmental Disorders

Intervention

Yoga, Exercise, Occupational Therapy, Behavior/play,

Aquatics, Classroom, School

Outcomes

Positive behavior, Behavioral outcomes, Social skills,

Appropriate response mechanisms

Databases and Sites Searched

PubMed
EBSCO multisearch
CINAHL
Cochrane
Google Scholar
AJOT

Quality Control/Peer Review Process:

-The focused question was consulted on and approved by course instructor.
-After initial development of key search terms, course instructor enhanced search terms and
databases used to ensure exhaustive search of relevant databases was completed.
-The students conducted searches in multiple databases and with help from the course instructor,
located and retrieved full-text articles of twenty studies identified in comprehensive literature
search.
-The students read and reviewed all articles for inclusion/exclusion criteria. Upon establishing
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

included articles, the course instructor helped ensure level of evidence of included articles was
indeed appropriate for appraisal.
-The students appraised ten articles determined to fit population, intervention and outcome
components while also meeting inclusion/exclusion criteria required to answer the focused
question in an Evidence Table. The Evidence Table was reviewed and critiqued by course
instructor.
-The students summarized the key findings and clinical significance of the reviewed articles from
the Evidence Table while referencing instructor feedback to complete the Critically Appraised
Topic.

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:

Level of
Evidence

Study Design/Methodology of Selected Articles

Number of Articles
Selected

Randomized controlled-trial

II

Two groups, nonrandomized studies (e.g. cohort, casecontrol)

III

One group, nonrandomized studies (e.g. before and

after, pre test, post test)

IV

Descriptive studies that include analysis of outcomes

(e.g. single subject design, case series)

Case reports and expert opinions, which include

narrative literature reviews and consensus statements

TOTAL:

Limitations of the Studies Appraised:

Levels I, II, and III
Level I:
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

The small sample size and cultural bias was a limitation to this study (Movahedi,
Bahrami, Marandi, Abedi, 2013, Level I).
Level II:
The sixteen week study prevented researchers from determining the long term effects
and would require further investigation (Koenig, Buckley-Reen & Garg, 2012, Level II).
Small sample size, negative behavior reduction did not reach statistical significance
(Magnusson, Cobham, McLeod, 2012, Level II)
The limitations of this study include the small sample size, small age range and single
gender of participants (all male) limit generalization. Second, even though an attempt
was made to obtain an equal size and type of ASDs in two groups of children with
ASDs, differences in cognitive abilities and gross motor skills were not evaluated and
might have influenced findings (Pan, 2010, Level II).
There is not a defined, representative sample of participants because there was no
information given on the control group, which decreases the internal validity. The
intervention was not clearly explained in the study. There were no psychometric
properties given for any of the three outcome measures so the reliability and validity of
these is unknown, which also decreases the internal validity. Because of the way the
participants were chosen, there could have been selection bias in the study. Bias could
have also been created because the ones implementing the intervention were the special
educators and parents who know the children well (Radhakrishna, Nagarathna &
Nagendra, 2010, Level II).
First, the current sample size is small thus must be considered a pilot study. Second, the
unequal treatment time between the experimental and control group may have
introduced certain bias to the nature of the results. Third, the confirmation of the ASD
diagnosis including the type and severity was not carried out (Tan, 2010, Level II).
Level III:
Main limitations included the small sample size consisting of eight children with
contrasting abilities. The use of more homogenous subgroups of children could
contribute to the heated debate about best treatment methods (Kok, Kong & BernardOpitz, 2002, Level III).
Limitations presented with this study was the lack of quantitative and qualitative data,
and evidence should be obtained with caution. There was no follow up with the
participants in the study so the long-term effects are unknown (Resenblatt et al., 2011,
Level III).

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Levels IV and V
The small sample size, limited space to perform physical activities, and
influence/motivation to participate may have affected the study (Nicholson, Kehle, Bray,
Heest, 2011, Level IV).

Other
N/A

Articles Selected for Appraisal:

Koenig, K., Buckley-Reen, A., & Garg, S. (2012). Efficacy of the get ready to learn yoga program
among children with autism spectrum disorders: a pretest-posttest control group design. The
American Journal of Occupational Therapy, (5) 66, 538-546.

Kok, A. J., Kong, T. Y., & Bernard-opitz, V. (2002). A Comparison of the Effects of Structured
Play and Facilitated Play Approaches on Preschoolers with Autism A Case Study. Autism,
6(2), 181-196. doi: 10.1177/1362361302006002005

Magnusson, J. E., Cobham, C., & McLeod, R. (2012). Beneficial effects of clinical exercise
rehabilitation for children and adolescents with autism spectrum disorder (ASD). Journal of
Exercise Physiology, 15(2), 71-79. Retrieved from
http://www.asep.org/asep/asep/JEPonlineApril2012Jane_Magnusson.pdf

Movahedi, A., Bahrami, F., Marandi, S. M., & Abedi, A. (2013). Improvement in social
dysfunction of children with autism spectrum disorder following long term Kata techniques
training. Research in Autism Spectrum Disorders, 7(9), 1054-1061. Retrieved from

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

http://www.sciencedirect.com/science/article/pii/S1750946713000834

Nicholson, H., Kehle, T. J., Bray, M. A., & Heest, J. V. (2011). The effects of antecedent physical
activity on the academic engagement of children with autism spectrum disorder. Psychology in
the Schools, 48(2), 198-213.

Pan, C.-Y. (2011). The efficacy of an aquatic program on physical fitness and aquatic skills in
children with and without autism spectrum disorders. Research in Autism Spectrum Disorders,
5(1), 657-665. doi: http://dx.doi.org/10.1016/j.rasd.2010.08.001

Radhakrishna, S., Nagarathna, R., and Nagendra, H.R. (2010). Integrated approach to yoga
therapy and autism spectrum disorder. Journal of Ayurveda & Integrative Medicine, (1) 2,
120-124. doi: 10.4103/0975-9476.65089

Rosenblatt, L., Gorantla, S. Torres, J., Yarmush, R., Rao, S., Park, E.,Levine, J. (2011)
Relaxation response based yoga improves functioning in young children with autism: a pilot
study. Journal of Alternative and Complementary Medicine, (11) 17, 1029-1035. DOI:
10.1089/acm.2010.0834

Tan, W. Z. B. (2011). Physical activity: its implication on attention span and quality of life in
children with Autism Spectrum Disorder. Retrieved from http://ro.ecu.edu.au/theses_hons/20/

Other References:
American Occupational Therapy Association. (2010). Autism statement. Retrieved from
http://www.aota.org/practitioners/official/statements/40880.aspx?ft=.pdf.
American Occupational Therapy Association. (2011). Occupational therapys role with autism.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Retrieved from http://www.aota.org/practitioners/resources/docs/factsheets

/children/38517.aspx
Centers for Disease Control and Prevention. (2012). Prevalence of autism spectrum disorders
Autism and Developmental Disabilities Monitoring Network, United States, 2008).
Mmwr, 61(SS3), 1-19.
Centers for Disease Control and Prevention. Data and statistics. (2013). Retrieved from
http://www.cdc.gov/ncbddd/autism/data.html

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05